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Journal of Religion & Spirituality in Social Work: Social Thought

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Spirituality in the treatment of substance use disorders: Proposing the Three-legged Stool as a model for intervention

E. Gail Horton & Naelys Luna

To cite this article: E. Gail Horton & Naelys Luna (2016) Spirituality in the treatment of substance use disorders: Proposing the Three-legged Stool as a model for intervention, Journal of Religion & Spirituality in Social Work: Social Thought, 35:3, 179-199, DOI: 10.1080/15426432.2015.1067585

To link to this article: https://doi.org/10.1080/15426432.2015.1067585

Published online: 22 Jun 2016.

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ARTICLE

Spirituality in the treatment of substance use disorders: Proposing the Three-legged Stool as a model for intervention E. Gail Horton, PhD and Naelys Luna, PhD

School of Social Work, Florida Atlantic University, Boca Raton, Florida

ABSTRACT Spirituality is a multidimensional construct that is considered to be a protective factor in the treatment of addictions. However, because there has been little agreement regarding the conceptualization of this complex construct, it has been difficult to operationalize spirituality in clinical settings so that its protective value can be maximized. This article presents a preliminary framework—the Three-legged Stool—to help thera- pists structure their spiritual interventions. The three “legs” of the spiritual “stool” consist of service (helping others), solitude (contemplative prayer and meditation) and creativity (creative arts and play therapy techniques). The authors begin by explaining the origin of the framework as it arose from their research and practice experiences. They conceptualize the dif- ferent components of the framework and present support for the inclusion of each leg with a review of the theoretical and empirical literature. Because this framework has not been tested empirically, the addictions research and treatment com- munities are asked to explore its strengths, limitations, and usefulness and to engage in conversations about how to utilize and improve the framework.

ARTICLE HISTORY Received 24 March 2015 Accepted 17 June 2015

KEYWORDS creativity; service; solitude; spirituality; substance abuse

Introduction

Spirituality has been considered to be of fundamental importance to the treatment of and recovery from substance use disorders for many years (Miller & Bogenschutz, 2008). Much of the literature on factors that are associated with positive substance abuse treatment outcomes suggests that spirituality is a protective factor in the recovery process (Kaskutas, Turk, Bond, & Weisner, 2003; Krentzman, Cranford, & Robinson, 2013; Piderman, Schneekloth, Pankratz, Stevens, & Altschuler, 2008; Sterling et al., 2007; Zemore, 2007a). In addition, individuals in recovery from addiction have reported that spirituality is more important than having a job; that attending spiritually based 12-step meetings is more important to their continuing recovery than outpatient therapy; and that they want a stronger emphasis

CONTACT E. Gail Horton, PhD [email protected] Florida Atlantic University, School of Social Work, 777 W. Glades Rd., #SO303, Boca Raton, FL 33431.

JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK: SOCIAL THOUGHT 2016, VOL. 35, NO. 3, 179–199 http://dx.doi.org/10.1080/15426432.2015.1067585

© 2016 Taylor & Francis

on spirituality when they are in treatment (Galanter et al., 2007). However, Miller (2013) has noted that although professionals in the addictions field verbalize an interest in spirituality as part of their clients’ treatment, few do more than simply encourage their clients to attend AA meetings as a way of addressing their spiritual issues. It is, therefore, not yet clear how spirituality should be infused into treatment settings; this is perhaps due to difficulties in conceptualizing and operationalizing the term (Canda & Furman, 2010; Cook, 2004). The purpose of this article is to explore how the multidimen- sional nature of spirituality might be used to develop a framework for intervention that mental health professionals could incorporate into their practice. We call the framework, which we will discuss in detail as follows, the Three-legged Stool. We envision spirituality to be the “seat” of the stool that is supported by the “legs” of service, solitude, and creativity (see Figure 1).

The idea for the Three-legged Stool has grown up slowly from our teaching and research experiences. First, we noticed that most textbooks used to teach courses about substance abuse and dependency have very little to offer concern- ing the spiritual dimension of human behavior and even less on the structure, content, or utility of spiritual interventions. Second, we have received feedback concerning the clinical implications of our correlational research on spirituality (concerning its relationship with attachment style and Axis I and II mental health disorders), from both editors and reviewers of peer-reviewed journals and from practitioners attending conferences where we have presented our results, that has prompted the development of the framework.

Spirituality

S er

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B ro

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Figure 1. Three-legged Stool of spirituality.

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Based on the conceptual and empirical support for each of the three legs as discussed in the following sections, we believe that the framework has the potential to assist professionals in treating their clients. However, we want to make it clear that no research has been conducted to explore the effectiveness of this framework and whether it can be used as a treatment model. We are proposing this framework to spur consideration, discussion, and research within the addictions community that may validate it as a treatment model.

We will begin our discussion of the proposed framework by discussing the definitions of spirituality that are used to support the framework and then presenting a review of the literature related to spiritual interventions in the treatment of substance use disorders. Then, conceptual and empirical evi- dence will be presented to justify the inclusion of each of the elements in the suggested framework. Lastly, limitations of the model and suggested direc- tions for future research are discussed.

Defining spirituality

Cook (2004) has pointed out that there is no clear understanding of the concept of spirituality evident in the addictions literature. For example, some researchers have utilized instruments that measure spiritual maturity (Hall & Edwards, 1996), transcendence of self (Piedmont, 1999), respondents’ image of a loving versus a controlling God (Benson & Spilka, 1973), quality of life (Daalman & Frey, 2004), and existential and religious well-being (Seidlitz et al., 2002). In the literature review of spiritual interventions presented as follows, even more measures of spirituality are utilized. In an effort to avoid these inconsistencies in the con- ceptualization and operationalization of spirituality, we are basing our proposed framework for spiritual intervention on the definitions provided as follows.

In defining spirituality, it is important to first distinguish between spiri- tuality and religion. Miller and Thorenson (2003) have pointed out that these two concepts, although closely related, are distinguishable from each other. They describe spirituality as being a multidimensional concept does not have a “tight definition” (p. 27), a problem that has made research on the subject difficult. Canda and Furman (2010) have argued that religion is “an institu- tionalized . . . pattern of values, beliefs, symbols, behaviors and experiences” (p. 76) associated with a particular community that may include spirituality as one of its defining features. Spirituality, on the other hand, both includes and transcends religion. They see spirituality as being “a universal quality of human beings and their cultures related to the quest for meaning, purpose, morality, transcendence, well-being and profound relationships with our- selves, others and ultimate reality” (p. 5).

Cook (2004) has based his definition of spirituality on a detailed review of 265 books and articles published between 1922 and 2001 concerning spiri- tuality. The definition that he constructed in response to his findings states

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that spirituality is “a distinctive, potentially creative and universal dimension of human experience” (p. 548) that may be experienced as a relationship with self, with others, or with that which is transcendent and beyond self. It is also experienced as being of “fundamental and ultimate importance” (p. 549) in a way that provides purpose and meaning to life.

These definitions by Canda and Furman (2010) and by Cook (2004) provide a foundation upon which we have based the Three-legged Stool framework. Service is seen as an avenue for the individual to enter into relationship with the core/force/soul of others in the broader community, which may provide them with existential purpose and meaning in life. Solitude (in the form of prayer and meditation practices) is seen as allowing individuals to access both their own core/force/soul and the Transcendent, which may allow them to access purpose and meaning in life and to free up their innate creativity. Creativity is seen as a route to self-knowledge and expression of the deepest self, arising from the core/force/soul of the indivi- dual and providing connection to the Transcendent.

Spirituality and substance use disorder treatment outcomes

Spirituality has a very long history in the treatment of addiction. In an article on the historical roots of faith-based recovery, White and Whiters (2005) reported that as early as the 18th century abstinence-based religious move- ments and the American temperance movement were calling for rejection of alcohol use. This was followed in the early 1900s by a more secular approach that combined psychological interventions with sober fellowship that encom- passed a connection to a religious community. Then, Alcoholics Anonymous (AA), an organization strongly influenced by evangelical Christians (Dermatis & Galanter, 2015), was formed in the 1930s. Emphasizing the religious underpinnings of AA, Dermatis and Galanter noted that AA holds that sobriety is achieved through a spiritual awakening and a surrendering of one’s will to God and pointed out that six of the 12 steps employed in AA refer to God (in the individual’s personal understanding of the God concept).

White and Whiters (2005) indicated that in the 1950s and 1960s there was a rise in faith-based treatment communities in response to a perceived increase in urban juvenile narcotics addiction. These authors also noted that with the impact of Malcom X on the consciousness of America during the 1970s, the Islamic community became much more deeply involved in recovery. According to Borne, Owens, Allen, and Vevaina (2000), during the 1990s, the protective value of religious participation and of the church as a strong support of mental health among Black women began to be recognized. In addition, Sloboda (2010) noted that the U.S. government became interested in allowing faith-based organizations to provide treatment services in the late 1990s and early 2000s, thus increasing the use of spiritual/religious interventions and research on them.

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This resulted in a spate of articles concerning a variety of congregational-based interventions (e.g., Califano, 2001; Lewis, 2003; Watson et al., 2003). Some of these interventions had a strong focus on Christian practices such as the use of the Bible and scripture (Havranek & Gilchrist, 2002). Thus, Miller (1998) was correct in noting that perspectives from religious and spiritual communities have historically shaped both treatment of and research on individuals with substance abuse problems.

Miller and Bogenschutz (2008) have noted that empirical studies of spiritual interventions in the treatment of alcohol and other substance use problems have been very limited. However, several longitudinal studies have indicated that spirituality is related to positive treatment outcomes (Piderman et al., 2008; Robinson, Cranford, Webb, & Brower, 2007; Robinson, Krentzman, Webb, & Brower, 2011; Sterling et al., 2007). For example, in a retrospective case control study, researchers matched 36 individuals who self-reported maintaining absti- nence for 3 months after successfully completing residential alcohol treatment with 36 individuals who relapsed before the 3-month follow-up (Sterling et al., 2007). Through paired t-test and ANOVA analyses, they found that, although both groups reported significant spiritual growth during their treatment epi- sodes, relapse was significantly associated with a decrease in scores on spiritual- ity/religious measures. Another longitudinal study of 74 individuals who attended outpatient services for alcohol dependence found that the strongest predictors of 1-year posttreatment abstinence were increases in private spiritual/ religious practices and levels of the spirituality dimension of purpose/meaning self-reported by the individuals at 12-month follow-up (Piderman et al., 2008). Other researchers performed logistic regression analyses using longitudinal survey data from 123 individuals receiving outpatient services for alcohol use disorders. Results showed that increases reported by participants in the purpose/ meaning dimension of spirituality significantly reduced the odds of relapse into heavy drinking at a 6-month follow-up (Robinson et al., 2007). In addition, findings revealed that increased purpose and meaning was related to positive drinking outcomes (percent of heavy drinking days and mean drinks per drinking day) at 9-month follow-up (Robinson et al., 2011).

Mediating effects of spirituality on treatment outcomes have also been documented in the literature. Using logistic and hierarchical regression analyses, Zemore (2007a) found that, in a sample of 733 individuals diag- nosed with chemical dependency in residential or day treatment facility, having a self-reported spiritual awakening acted as a mediator between increasing AA involvement and past-month abstinence at a one-year fol- low-up. Another study analyzed Project MATCH data (a randomized con- trolled trial of psychosocial treatments for alcohol use disorder in a sample of 1,726 individuals) using general linear modeling and controlled lagged med- iational analyses (Kelly, Stout, Magill, Tonigan, & Pagano, 2011). Based on the participants’ reports of their behaviors, results indicated that number of

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drinks per drinking day, percent of days abstinent, and AA meeting atten- dance were mediated by level of spiritual/religious behaviors and practices.

Other studies, however, have not found evidence for a mediating effect. For example, Magura and colleagues (2003) utilized self-report instruments in a prospective longitudinal study of 276 randomly assigned members of several dual-diagnosis 12-step mutual aid groups to examine the possibility that spiri- tuality might mediate a relationship between the depth of individuals’ involvement in the groups and 1-year abstinence. Primary substances abused by participants were cocaine, alcohol, heroin, or marijuana while their mental health diagnoses included schizophrenia, major depressive disorder, and bipolar disorder. Results of logistic regressions indicated that there was no mediating effect. Similarly, Tonigan (in Owen et al., 2003), conducting structural equation modeling on data from Project MATCH, found that the relationship between level of involve- ment in AA and percent of days abstinent was not mediated by the extent of the respondent’s self-perceived spiritual awakening. In a later study comparing 12- Step Facilitation Therapy with Motivational Interviewing and Cognitive- Behavioral Therapy (Tonigan, in Longabaugh et al., 2005) MANCOVA analyses found that while those undergoing the 12-step therapy reported that they had higher levels of spirituality than those undergoing the other modalities, spirituality was not related to four measures of drinking at a 6-month follow up.

From this review of the literature, it is clear that spiritual interventions are not uniformly positive in their effectiveness. The mixed results concerning their value may be a product of the problem of definition and operationali- zation of the term spirituality. However, we believe that there is enough evidence indicating that spiritual interventions may be of benefit to indivi- duals struggling with addiction. Therefore, we feel justified in suggesting the Three-legged Stool model for increasing spirituality among this population.

In the remainder of this article, we will justify the inclusion of service, solitude, and creativity as parts of the framework by presenting a review of the theoretical and empirical literature as it pertains to the treatment of addiction.

Service

The definition of the term service in the context of the Three-legged Stool framework is based on a description by Zemore and Pagano (2008) of the AA approach to helping. This approach defines spirituality as being any volun- tary and intentional action by an individual which provides emotional or instrumental help to other individuals or to the broader community and for which there is no expectation of any external reward. Research has provided strong evidence for a causal relationship between volunteering and positive well-being in the general population (Pilivian & Siegl, 2007), and because of its prominent place in 12-step recovery models, service seems to fit naturally into our framework.

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Conceptual support for the inclusion of service

Service to others has long been an important part of a strong spiritual life (Sher & Straughan, 2005). Musick and Wilson (2003) suggested that helping others results in enhanced self-esteem as well as increased purpose and meaning in life. Furthermore, helping is a main tenet of 12-step groups such as AA that is thought to be fundamental to sustained abstinence in recovery (Humphreys, 2004; Tonigan, 2007). Zemore (2007b), in her writings concerning helping behaviors in AA, goes so far as to say that, because service has been recognized as an important activity in most of the major religions, it can be understood as “the behavioral expression of a spiritual orientation” (p. 447). Given that service is seen as fostering both purpose/ meaning and acceptance by others, and because it has been such a funda- mental part of the spiritually based 12-step model of addiction recovery, it is reasonable to include it in the Three-legged Stool framework.

Empirical support for the inclusion of service

Though research on helping and spirituality in the treatment of addiction is still somewhat sparse, we feel that the existing studies discussed as follows justify the inclusion of service in the Three-legged Stool framework because of its potential to increase connectedness to others and purpose and meaning in life. Within the addictions literature, several methodologically sound studies have examined the relationship between service activities and spiritually based recovery programs and recovery outcomes (Pagano, Friend, Tonigan, Scott, & Stout, 2004; Pagano, Zemore, Onder, & Stout, 2009; Witbrodt & Kaskutas, 2005; Zemore, Kaskutas, & Ammon, 2004). Two studies, utilizing data from a large Project MATCH data base, showed that self-reported AA-related helping was significantly associated with a reduced probability of relapse among participants with diagnosed alcohol use disorder 1 year after treatment completion (Pagano et al., 2004). Although Project MATCH allows analysis of large numbers of individuals, the design did not include a control group and so no causal relationships between helping and relapse rates can be drawn.

In a randomized control design study of individuals with diagnosed sub- stance use disorder, researchers found that involvement in the service com- ponent of 12-step groups was the best predictor of abstinence at 1-year posttreatment among a group of eight 12-step variables (e.g., meeting atten- dance, having a sponsor) and 10 social network variables (e.g., number of friends who do not use at all, who actively support sobriety; Witbrodt & Kaskutas, 2005). Other research has indicated that helping behaviors were significantly related to subsequent 12-step involvement and that they were also significantly related to reduced binge drinking after discharge (Zemore et al., 2004).

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In further research on the spiritual component of AA, Zemore and Kaskutas (2004) explored the relationships between spirituality, helping behaviors, AA participation, and length of sobriety among a convenience sample of 257 recovering alcoholics. They found that length of sobriety was positively related to both experiences of God and perception of connected- ness with others and the universe, suggesting that these factors may provide purpose and meaning in life that could help to maintain motivation for abstinence. In addition, they reported strong relationships among both of the spirituality variables and all three kinds of helping behaviors, which they felt was consistent with the view that helping is an expression of spirituality.

Solitude

The term solitude has been intentionally and thoughtfully chosen within the context of the Three-legged Stool framework to refer to activities related specifically to meditation and/or prayer. We have chosen this term because although both prayer and meditation may certainly be conducted as a corporate activity within religious settings or as a group spiritual activity, we feel that the term solitude connotes the very personal and internal experience mentioned in the definitions of spirituality provided by Cook (2004) and Canda and Furman (2010) on which we are basing our framework.

Our focus on the internal rather than the corporate aspect of prayer/ meditation is not meant to suggest that group activities are in any way to be discouraged among individuals with substance use issues who are inter- ested in corporate religious practices as part of their spiritual lives. Instead, it is the quieting of the mind that we are emphasizing in an effort to encourage individuals to go deep inside themselves to further their sense of connected- ness to core self and to the Transcendent through silence and personal reflection.

We also need to distinguish between the terms solitude and aloneness. According to Bernstein (2012), the term aloneness connotes frightening disconnection and abandonment while solitude suggests comfort with being without others. We are proposing that meditation and contemplative prayer be considered as potential interventions to increase spirituality in a substance-abusing population specifically because of the opportunity for solitude and reflection that they can provide.

Meditation

Conceptual support for the inclusion of meditation In the mid-1990s the literature on both mental and physical health began to show an increase in interest in meditation and prayer as viable prevention

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and intervention techniques. This interest sprang from the pioneering work of Larson who conducted extensive scientific research demonstrating the significance of incorporating faith, spiritual practices, and religious beliefs into the prevention and treatment of multiple behavioral and psychological disorders, including addiction (Larson & Larson, 1994; Larson, Sherill, & Lyons, 1994). Marlatt (2002) has noted the Buddhist roots of meditation techniques and suggested that meditation based on Buddhist philosophy provides a spiritual, though nontheistic alternative to the strong theistic emphasis of 12-step groups. The noticing of thoughts as they arise and then subside during meditation is related to the Buddhist concept of imper- manence in which it is understood that all thoughts, feelings, and images change whether they be positive (like the feeling of being high) or negative (like craving). According to Marlatt, meditation helps clients develop a different attitude and relationship with their thoughts and feelings in which they can engage in “urge surfing” (p. 47) that will allow the urge to build up, crest, and then pass. Activities that promote mindful awareness through contemplation and solitude may help substance dependent clients under- stand impermanence and better tolerate their current negative experiences (Marlatt & Chawla, 2007). From the perspective of the Three-legged Stool framework, meditation and contemplation as understood by Marlatt (2002) may be expected to help individuals detach from their addictions and open up a new knowledge of their core selves while increasing their connectedness with the Transcendent.

Empirical support for the inclusion of meditation According to Brown, Ryan, and Creswell (2007), the most common form of meditation utilized in current research is called Vipassana, or mindfulness, meditation. They defined mindfulness as being “a receptive attention to and awareness of present events and experience” (p. 212). That is, when an individual is in a mindful state, he or she is able to be present to whatever feelings, thoughts, memories, impulses, or sensations that he or she is experiencing in the moment without automatically reacting to them with a habitual and often unconscious response.

There is some evidence that mindfulness meditation may hold benefits for treatment with this population, but no studies have been conducted that could indicate a causal connection between meditation and abstinence. In addition, the evidence linking meditation and positive outcomes has not been consistent. A longitudinal study by Bowen and colleagues (2006) compared incarcerated individuals with histories of alcohol and/or illicit drug abuse who participated in a 10-day marathon Vipassana meditation course with those who received treatment as usual. They found that those who partici- pated in the meditation course self-reported significantly less alcohol, mar- ijuana, and cocaine use, as well as significantly lower levels of psychiatric

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symptoms, higher levels of alcohol-related internal locus of control and higher levels of optimism, at 3-month postincarceration follow-up than those who received treatment as usual.

In contrast, in a pilot trial of mindfulness meditation for treatment with substance abuse clients, researchers utilized random placement of individuals in a recovery house into either standard treatment or in standard treatment plus mindfulness meditation (Alterman, Koppenhaver, Mullholand, Ladden, & Baaime, 2004). These researchers did not find significant differences between the groups in urine toxicology during treatment, or at 2-month or 5-month follow-up. However, they did note decreased medical problems among those engaging in meditation and increased medical problems among those who did not engaged in meditation. They suggested that, since this group of participants had relatively severe addiction and a history of poor social adjustment that may have affected their ability to gain benefit from the intervention, the effectiveness of meditation to address substance use problems may vary among different groups and individuals.

Although research on the possible value of mindfulness meditation in the treatment of substance use disorders is admittedly sparse, several therapeutic models based on mindfulness have been developed and empirically validated in recent years for use in other clinical populations. In some of the models discussed as follows, formal meditation techniques are employed but in others they are not.

Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) utilizes mindfulness techniques as part of a multicomponent interven- tion to reduce the emotional avoidance common among individuals in treatment for substance use disorders. The developers of the model believe that ACT helps clients develop an observing self that allows them to distin- guish between different types of thoughts—descriptive, evaluative, and dis- tortion. Dialectical Behavior Therapy (DBT; Linehan et al., 1999) combines traditional cognitive behavioral therapy techniques with mindfulness medita- tion techniques in an effort to get the client (specifically, borderline person- ality disorder clients) to accept unpleasant emotions as impermanent and modify their dysfunctional thinking associated with substance use. While ACT and DBT utilize mindfulness as one among several therapeutic ele- ments, mindfulness-based stress reduction (MBSR; Miller, Fletcher, & Kabat- Zinn, 1995) and mindfulness-based cognitive therapy (Teasdale et al., 2000) make mindfulness the centerpiece of therapy for depression and anxiety, which are highly comorbid with substance use disorders.

It should be noted that although these therapies are not considered to be spiritual interventions, each one emphasizes the need for clients to become more aware of their core selves, an important part of spirituality as defined in this article.

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Prayer

Conceptual support for the inclusion of prayer It has been suggested that, from an attachment theory perspective, God may be conceptualized “as a member of the client’s relational system” and that improvement in an individual’s relationship with God may result in improve- ment in other relationships in his or her life (Jankowski, 2006, p. 241). Contemplative prayer can be understood as a way of activating an individuals’ attachment behavioral system with his or her Deity, which results in an increased sense of hope engendered by the felt security with God (Jankowski & Sandage, 2011).

Juhnke, Watts, Guerra, and Hsieh (2009) have noted that within the addiction community, 12-step programs have traditionally incorporated prayer and meditation as a required part of the program. Recovering indivi- duals who utilize these mutual-help groups are familiar with praying because it is included in the 11th step: “we have sought through prayer and medita- tion to improve our conscious contact with God as we understood him, praying only for knowledge of His will for us and the power to carry that out” (Alcoholics Anonymous World Services, 2001, p. 59). Individuals who struggle with substance use problems also commonly use the Serenity Prayer (Niebuhr & Brown, 1987) within many of these groups. This tradition of prayer and meditation is clearly meant to increase an individual’s connect- edness with the Transcendent.

From the preceding discussion of solitude, it can be seen that solitude in the form of contemplative practices may have the potential to increase spirituality by improving connectedness to both others and to the Transcendent. Therefore, we include it in our Three-legged Stool framework.

Empirical support for the inclusion of prayer Unfortunately, unlike the literature of meditation discussed previously, there are no studies currently in the literature that provide empirical support for the use of prayer to reduce substance use problems or to increase abstinence. However, prayer has been shown to be related to improvements in mental health problems that frequently co-occur with substance abuse and depen- dency. For example, in an early, small study of the use of contemplative prayer as an adjunct to psychotherapy with adults, prayer was shown to be associated with both a decrease in participants’ negative feelings and with a slight increase in their spirituality (Finney & Malony, 1985). In a more recent investigation, meditative prayer was a statistically significant predictor of lower levels of depression, anxiety, somatic complaints and social dysfunc- tion (problems that are commonly co-morbid with substance use disorders), and higher levels of existential well-being (purpose/meaning) among a com- munity sample of British adults (Maltby, Lewis, & Day, 2008).

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Creativity

Webster’s online dictionary defines creativity as “a mental and social process involving the generation of new ideas or concepts, or new associations of the creative mind between existing ideas or concepts . . . fueled by the process of either conscious or unconscious insight” (http://www.websters-online-diction ary.org/definitions/Creativity). Siegel (2012), on the other hand, has defined creativity as “a way of being in which life emerges in new and fresh combina- tions of inner experiences and outer explorations” (pp. 17–18) that leads to both mental and physical health. Cropley (2006) has also noted that early mental health practitioners and theoreticians such as Maslow, May, and Rogers looked at creativity as “a form of self-expression . . . that is intimately connected with personal dignity, expression of one’s inner being, self-actuali- zation and the like” (p. 125). Based on these definitions, creativity in the context of the proposed Three-legged Stool framework is understood to be the clients’ bringing forth new and fresh ideas arising from either the conscious or unconscious mind and providing an avenue for expression of the inner self (core/force/soul) as well as purpose and meaning in life.

A review of the literature concerning creativity, spirituality, and substance abuse treatment outcomes highlights serious gaps that we have encountered in attempting to justify the inclusion of creativity as a valid spiritual inter- vention. We were unable to find empirical articles about creativity per se. Instead, we have found in the literature articles that describe the clinical use of two types of creative therapy: creative arts therapy and play therapy. Although none of the interventions described have been empirically validated through studies with rigorous experimental methodologies, we include these creative therapies because their authors appear to be genuinely convinced that the changes they witnessed in their clients were due to creative activities or play. The following subsections discuss the conceptual and empirical support for creative arts therapy and play therapy.

Creative arts therapy

Conceptual support for the inclusion of creative arts therapy Creative arts therapy, sometimes called recreational therapy, includes a variety of modalities that utilize poetry, drama, dance, music, writing, draw- ing, painting, and so forth to treat a broad spectrum of populations from neonatal nurseries to nursing homes (see the National Coalition of Creative Arts Therapies Associations at http://www.nccata.org/#). Although empirical support for the use of creative arts as a spiritual intervention is not yet available, there is some theoretical support for its inclusion in our frame- work. Creative activities have often been closely associated with spirituality in literature (Armstrong, 1993; Damianakis, 2001; Edwards, 2000). Damianakis

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(2001) has argued that creative writing of any sort (not limited to poetry or fiction, but including any writing original to the writer) is a naturally spiritual act. This author links the process of creative writing to Maslow’s (1968) concept of self-actualization that occurs through self-transcendence which leads to “a deeper sense of eternity, connection to others and the cosmos” (p. 26). In addition, Oreskovic and Bodor (2010) have pointed out that substance abuse itself interferes with the ability to creatively face life problems by damaging the areas of the brain responsible for maintaining balance in cognitive and emotional functioning. These ideas suggest that encouraging creative activities among clients in substance abuse treatment may increase a sense of connectedness to self (core/force/soul), others and the Transcendent and as a possible source of help in regaining cognitive and emotional balance.

Empirical support for the inclusion of creative arts therapy In our literature review five studies published between 1990 and 2007 exploring creative arts interventions in the treatment of addiction were found (Feen- Calligan, 2007; Johnson, 1990; Julliard, 1995; Matto, 2002; Reiland, 1990). All of these studies were descriptive and exploratory, and involved either single subject case designs or very small samples of individuals in detox (Feen-Calligan, 2007), inpatient (Matto, 2002; Reiland, 1990), partial hospitalization (Johnson, 1990), or intensive outpatient (Julliard, 1995) settings. Therefore, it must be noted that no causal connections between creative arts therapy and positive substance abuse outcomes yet exist. Creative arts therapy techniques included drawing (Reiland, 1990), poetry, art, dance, and music/drama performance therapies (Johnson, 1990), multimedia collage and role plays (Julliard, 1995), art therapy combined with cognitive-behavioral therapy (Matto, 2002), and art and creative journaling (Feen-Calligan, 2007). None were able to provide statis- tically significant correlations between these techniques and participants’ absti- nence. However, it is clear from these preliminary studies that the researchers genuinely believed that their creative arts techniques were valuable to their clients. For instance, Matto (2002) and Reiland (1990) stated that their creative art techniques had increased their clients’ self-awareness. Julliard (1995) and Matto (2002) believed that the creative arts had helped their clients to break through denial and become aware of powerlessness over their addiction (Julliard, 1995; Matto, 2002). One author reported that her clients, through the use of the creative arts, were able to overcome recovery-related shame (Johnson, 1990), and another saw an increase in problem-solving capabilities and con- nectedness to the Transcendent (Feen-Calligan, 2007).

Although the utility of creative arts interventions has not yet been inves- tigated using experimental designs, the small number of descriptive and correlational studies discussed previously suggest that art therapy may be useful in addressing issues commonly found in addictions treatment.

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Creative activities may result in an increased knowledge and expression of clients’ core/force/soul, relatedness to their Higher Power, and the develop- ment of purpose and meaning. Therefore, we believe that the use of the creative arts may be beneficial in the treatment of clients with SUDs.

Play therapy

Conceptual support for the inclusion of play therapy Play therapy includes a wide array of possible activities including role play, psychodrama, verbal play (humor), playing with dolls, sand tray, and games (Schaefer, 2003). However, one author has employed sand tray with her clients suffering from grief, depression, and trauma (Amatruda, 2003), and she concluded that the experience helped them to find their “center, whole- ness, and a connection to the divine” (p. 255). McDargh (1986) has noted that play is the capacity for relaxed, spontaneous, and unguarded experien- cing of the self’s agency and creativity in acting upon the world: “In play, the [individual] tries on roles, tests limits, explores the world, experiments with emotions that outside the space of play would be too daunting or problematic or anxiety provoking” (p. 259).

In addition, she suggested that “for many persons it is the inner repre- sentation of God that is the effective guarantor of play . . . that evokes the environment within which emotional refueling can take place, and the self restored and recuperated” (p. 259). These ideas concerning creativity/play and development of self appear to be related to the self/core/soul aspect of spirituality. Therefore, from the perspective of the Three-legged Stool frame- work, play therapy may have the potential to promote connectedness to core self, to others, and to the Transcendent and could be considered as the focus of future research.

Empirical support for the inclusion of play therapy Play therapy is not generally thought of as a spiritual intervention and, similar to the creative arts therapy literature, there is no existing empirical research exploring its use among clients experiencing SUDs. However, find- ings associated with a qualitative study of four adult male repeat offenders mandated to receive substance abuse treatment for cocaine, methampheta- mine, and/or other stimulant use suggested that participating in a sand tray intervention may have been beneficial (Monakes, Garza, Wiesner, & Watts, 2011). After analysis of transcribed audiotaped interviews with the clients, the authors found an association between the use of the sand tray and a greater willingness of clients to delve deeper into their issues than talk therapy had taken them. They suggested that the intervention may have resulted in an increase in the clients’ relatedness to their therapist.

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Several other articles and book chapters have described the implementa- tion of psychodrama techniques among individuals with substance use issues (Avrahami, 2003; Ramseur & Wiener, 2003; Somov, 2008; Treadwell, Kumar, & Wright, 2010). Somov (2008) described an addiction-specific psychodrama group which allowed residential clients with alcohol and other drug use problems to practice their relapse prevention skills and treatment termina- tion plans. Ramseur and Wiener (2003) stated that they used psychodrama to develop trust and interdependence in group members and skills needed for the maintenance of sobriety among individuals in treatment for alcohol- and other drug-related problems. Several other authors have discussed the possi- ble utility of integrating psychodrama and cognitive behavioral therapy in the treatment of addiction (Avrahami, 2003; Treadwell et al., 2010) concluding that psychodrama was a valuable asset in assisting their clients in changing their faulty thinking patterns. It must be emphasized, however, that because of the descriptive nature of the studies, causal relationship between the psychodrama techniques and client improvements could not be established.

Limitations and future directions for research

As the discussion of the literature concerning empirical support for each of the elements in the proposed framework shows, there is a woeful lack of metho- dologically sound empirical studies examining the effect of service opportu- nities, prayer/meditation, or the creative arts on the treatment of addiction and the achievement and maintenance of abstinence. Instead, research tends to be descriptive and to focus on case studies rather than providing solid quantita- tive data. We are currently conducting a pilot study in which we ask clients attending a residential treatment program for substance use issues if the service, prayer/meditation, and creative interventions already offered by the treatment program have helped them in their attempt to complete treatment successfully. This is a mixed method study that explores clients’ perceptions of usefulness of art therapy, Christian prayer and meditation groups, and service components currently offered by the substance abuse treatment program in which they are enrolled. We are also interested in gaining an understanding of how the spiritual dimensions of core/force/soul, purpose/meaning and relat- edness to self, others, and the Transcendent are understood by clients. Our efforts, however, will clearly not be enough to fill this gap in the literature. We are hoping that our discussion of the Three Legged Stool framework may spur others to join in this investigation.

Future research could consider the possibility of adding more legs to the stool as other constructs may also increase spirituality. For example, recent studies report that forgiveness may be a factor associated with both spiri- tuality and substance abuse treatment outcomes (Lyons, Deane, Caputi, & Kelly, 2011; Lyons, Deane, & Kelly, 2010). Prayer and meditation as

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suggested in our Three-legged Stool model would also probably fit well into a model that includes forgiveness. In addition, self-compassion developed through the practice of mindfulness-based stress reduction techniques has shown promise in increasing spirituality (Bernie, Speca, & Carlson, 2010) and might be considered a possible leg. Other possibilities may also occur as researchers and practitioners consider the model over time.

Future research could also explore causal connections between the legs and spirituality. For example, does creativity have a direct impact on the development of spirituality or is it a mediating factor that allows an indivi- dual to feel connected to his or her higher power? Would forgiveness, if included as a leg, increase the individual’s level of spirituality or be increased through spiritual growth?

In addition, future research examining the usefulness of the proposed framework in the treatment of particular groups of individuals would also be valuable. For example, it may be particularly important that research be conducted on how individuals with co-occurring psychiatric disorders would respond to interventions suggested by the Three-legged Stool framework since such a large number of individuals (approximately 1.2 million people accord- ing to Cranford, Nolen-Hoeksema, & Zucker, 2011) suffer from co-occurring alcohol and mental health disorders each year. In addition, as Alterman and colleagues (2004) have suggested, meditation seems to be more effective in reducing substance use in some groups of individuals than in others. Therefore, research could focus on differences between levels of treatment, for example, comparing the use of meditation (as well as creative arts and service) in the treatment of individuals at the outpatient (or other) level with its use among inpatients. Furthermore, the framework should be tested in a culturally diverse sample to determine if different cultures respond differently to its elements. It would also be useful to compare a group of individuals in treatment for addictions with individuals not in addiction treatment concern- ing their understanding of spiritual dimensions and the value of creativity, service, and prayer/meditation to their spiritual well-being.

Most importantly, interventions containing service, solitude, and creativity need to be examined for their utility in promoting and maintaining absti- nence. Future research also needs to establish causal effects of these spiritual interventions by conducting randomized control studies with follow-up procedures to determine if effects of the interventions on abstinence can be seen longitudinally.

Conclusion

The aim of this article was to introduce a framework of spiritual intervention —the Three-legged Stool—to the addiction community for consideration and discussion as a viable way to target specific aspects of spirituality. The

194 E. G. HORTON AND N. LUNA

framework conceptualizes spirituality as a stool which uses service, solitude, and creativity as the “legs” that support the “seat” of spirituality. It is our hope that the framework can be utilized to maximize the usefulness of spirituality in the treatment of individuals with substance use issues. It has not been our intention to suggest that the Three-legged Stool framework is the only model that could address spiritual development because there is no empirical validation of the framework at this time. Instead, we are encoura- ging the addiction community to engage in a conversation about how to increase spirituality among individuals in treatment and to examine this and other models that may help these individuals. It is hoped that, through our own and other research efforts, therapists in the field of addiction will be able to take concrete actions to facilitate the development of spirituality both during and after treatment as they attempt to improve clinical outcomes.

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